Provider Demographics
NPI:1629747605
Name:VICK, PENELOPE (MPH, LBS)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:
Last Name:VICK
Suffix:
Gender:F
Credentials:MPH, LBS
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:
Other - Last Name:VICK HENDRIX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPH, LBS
Mailing Address - Street 1:225 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-2124
Mailing Address - Country:US
Mailing Address - Phone:646-479-6154
Mailing Address - Fax:
Practice Address - Street 1:225 CHURCH ST
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-2124
Practice Address - Country:US
Practice Address - Phone:646-479-6154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005463103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst